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Otimização da transição hospital / domicílio: Projeto de implementação de um programa de acompanhamento de doentes crónicos complexos no serviço de medicina
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| 1.15 MB | Adobe PDF |
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Abstract(s)
O presente relatório, elaborado no contexto do curso de Mestrado em Enfermagem Médico-cirúrgica, na pessoa em Situação Crónica, dá conta do caminho percorrido para a elaboração de um projeto que visa a implementação de um programa de acompanhamento de doentes crónicos complexos, no serviço de medicina.
Este trabalho resulta da reflexão da realidade atual nos serviços de internamento de medicina, em que se verifica um progressivo envelhecimento dos doentes internados, associado à multimorbilidade e à polimedicação, o que se traduz em cuidados mais complexos. Acontece que os cuidados de saúde ainda estão organizados num modelo orientado à doença aguda, com respostas episódicas e reativas, focado em formas de tratamento que não são adequadas às necessidades dos doentes crónicos. Estes doentes crónicos requerem uma monitorização e uma intervenção multidisciplinar, mais focadas nas suas necessidades complexas enquanto pessoas, do que nas próprias doenças crónicas.
Atendendo a esta necessidade, foi elaborado um programa de acompanhamento de doentes crónicos complexos (PADcc), cujo intuito é promover a capacitação do doente, e/ou cuidador, na gestão da doença e do regime terapêutico, que contribua para uma utilização mais eficiente dos recursos em saúde. Para tal, o programa criado baseou-se no modelo de cuidados da gestão de caso, passando a sua concretização pela criação da figura de enfermeiro gestor de caso no serviço de medicina. Assim, adotando um programa com percursos definidos é apresentado e sistematizado um acompanhamento do doente e cuidador, desde o internamento até ao domicílio.
Para implementar este programa de acompanhamento em proximidade ao doente crónico complexo (PADcc), no serviço de medicina, é apresentado o processo de conceção do projeto, com o diagnóstico da situação, a apresentação do planeamento, com a definição da finalidade e objetivos e o desenvolvimento das atividades que permitem a concretização desses mesmos objetivos. Face a limitações temporais decorrentes do contexto académico em que este projeto foi elaborado, não foi possível avançar para a fase de execução.
This report, written in the context of the master's degree course in Medical-Surgical Nursing for the chronically ill, describes the path taken to develop a project aimed at implementing a program to monitor complex chronically ill patients in the medical service. This work is the result of reflecting on the current reality in medical inpatient services, where there is a progressive ageing of inpatients, associated with multimorbidity and polymedication, which translates into more complex care. The fact is that healthcare is still organized around an acute disease model, with episodic and reactive responses, focused on forms of treatment that are not suited to the needs of chronic patients. These chronic patients require multidisciplinary monitoring and intervention, more focused on their complex needs as people than on the chronic diseases themselves. In view of this need, a program for monitoring complex chronic patients (PADcc) was designed, the aim of which is to promote the empowerment of the patient and/or caregiver in the management of the disease and the therapeutic regime, and to contribute to a more efficient use of health resources. To this end, the program was based on the case management model of care, and its implementation included the creation of a nurse case manager in the medical service. Thus, by adopting a program with defined pathways, monitoring of the patient and caregiver is presented and systematized, from hospitalization to home. In order to implement this program of close monitoring of the complex chronic patient (PADcc) in the medical service, the project design process is presented, with a diagnosis of the situation, the presentation of the planning, with the definition of the purpose and objectives and the development of the activities that enable these objectives to be achieved. Due to time constraints arising from the academic context in which this project was drawn up, it was not possible to move on to the implementation phase.
This report, written in the context of the master's degree course in Medical-Surgical Nursing for the chronically ill, describes the path taken to develop a project aimed at implementing a program to monitor complex chronically ill patients in the medical service. This work is the result of reflecting on the current reality in medical inpatient services, where there is a progressive ageing of inpatients, associated with multimorbidity and polymedication, which translates into more complex care. The fact is that healthcare is still organized around an acute disease model, with episodic and reactive responses, focused on forms of treatment that are not suited to the needs of chronic patients. These chronic patients require multidisciplinary monitoring and intervention, more focused on their complex needs as people than on the chronic diseases themselves. In view of this need, a program for monitoring complex chronic patients (PADcc) was designed, the aim of which is to promote the empowerment of the patient and/or caregiver in the management of the disease and the therapeutic regime, and to contribute to a more efficient use of health resources. To this end, the program was based on the case management model of care, and its implementation included the creation of a nurse case manager in the medical service. Thus, by adopting a program with defined pathways, monitoring of the patient and caregiver is presented and systematized, from hospitalization to home. In order to implement this program of close monitoring of the complex chronic patient (PADcc) in the medical service, the project design process is presented, with a diagnosis of the situation, the presentation of the planning, with the definition of the purpose and objectives and the development of the activities that enable these objectives to be achieved. Due to time constraints arising from the academic context in which this project was drawn up, it was not possible to move on to the implementation phase.
Description
Keywords
Doente crónico Enfermeiro gestor Programa de acompanhamento hospital / domicílio Trabalho de projeto